DRG高倍率病例成因及其管控路径研究  

Research on the Causes of DRG High-Rate Cases and Their Control Pathways

作　　者：魏苏璟 谈在祥 杨晶 Wei Sujing;Tan Zaixiang;Yang Jing(Affiliated Xuzhou Clinical College of Xuzhou Medical University,Xuzhou,Jiangsu,221006,China;不详)

机构地区：[1]徐州医科大学徐州临床学院,江苏徐州221006 [2]徐州医科大学管理学院,江苏徐州221004 [3]徐州医科大学附属医院,江苏徐州221006 [4]徐州市医疗保障局,江苏徐州221006

出　　处：《中国医院管理》2025年第2期53-56,73,共5页Chinese Hospital Management

基　　金：徐州市重点研发计划(社会发展)项目(KC22157)。

摘　　要：目的 分析疾病诊断相关分组高倍率病例的成因,并提出有效的管理对策,以应对高倍率病例对医院经济和医疗服务质量带来的挑战。方法 采用Excel 2021对6 937例高倍率病例和120 782例正常倍率病例的数据进行分析,同时结合医疗质量督查结果分析高倍率病例产生的原因。结果 高倍率病例相较于正常病例,具有更高的平均基准点数和次均住院费用,特别是基准点数超过300的高倍率病例次均住院费用高达151 906.70元。高倍率病例集中于有创呼吸机支持≥96小时或ECMO或全人工心脏移植术等复杂病组。结论 高倍率病例的主要成因包括疑难危重病例、医生与编码员的操作失误、过度诊疗和“低编高套”行为。为有效控制高倍率病例的数量,改善医疗服务质量,减轻医院经济压力,应完善医保配套政策、加强医疗团队培训、推进信息化建设、制定临床路径和强化医疗监管等措施。Objective To analyze the causes of high-rate DRG cases and to propose effective management countermeasures to address the challenges posed by high-rate cases to the economy of hospitals and the quality of medical services. Methods Data of 6 937 high-rate cases and 120 782 normal-rate cases were analyzed using Excel2021, and the causes of high-rate cases were analyzed in conjunction with the results of medical quality inspections. Results High-rate cases exhibit significantly higher average benchmark points and per capital hospitalization costs compared to normal cases,especially those with benchmark points exceeding 300,where the average cost reaches up to 151 906.70 yuan. The high-rate cases were concentrated in the group of complex diseases such as invasive ventilator support ≥96 hours or ECMO or total artificial heart transplantation. Conclusion The main causes of high-rate cases include complex and severe cases,operational errors of doctors and coders,over-treatment, and the practice of “under-coding with over-charging”. To effectively control the number of high-rate cases,improve the quality of medical services,and alleviate the economic pressure on hospitals,the following countermeasures were proposed: improving medical insurance supporting policies, strengthening the training of medical teams,promoting the construction of information technology,formulating clinical pathways,and reinforcing medical supervision.

关 键 词：高倍率病例 疾病诊断相关分组 管控路径 

分 类 号：R197.1[医药卫生—卫生事业管理]